Strategy for elimination of leprosy in india..skp

STRATEGY FOR ELIMINATION OF

LEPROSY IN INDIA

DR.SUDHIRA KUMAR PARIDA

WORLD: Over past 20 yrs,14 million pts cured;4million

since 2000. PR has dropped by

90%(1985:21.1/10,000 .2000:1) Globan burden has declined

dramatically(1985:5.2million cases,2009:2.04lakh) Has been Eliminated from 119 of 122 countries. To date,there has been no resistance to MDT Efforts currently focus on eliminating leprosy at a

national level in remaining endemic countries & at a sub-national level from others.

INTRODUCTION

2009: 2,44,796 new cases Registered prevalence at the beginning of

2010:2,11,903 No. of new cases in 2009 in 16 countries that reported 1000 new cases accounted for 93% of all new cases

Among new cases in 2009: MB-67.93%(SEAR:42.89% in Bangladesh to 82.43% in Indonesia)

Proportion of females among newly detected cases in 2009 was 43.71%(SEAR:33.13% in Timor to 43.52% in Sri Lanka)

Proportion of children15 yrs was 10.97%(SEAR:3.67% in Thailand to 12% in Indonesia)

Proportion of new cases with grade2 disability was 7.04%(SEAR:3.08% In India to 14.9% in Myanmar)

No. of relapses remained low at 1.52%SEAR:

58.8% of global prevalence at the beginning of 2010 67.8% of all new cases in 2009

As on 1981PR: 57.60/10,000

As on Mar.2001PR: 3.74/10,000

Andaman&Nicobar Islands

AndhraPradesh

Arunachal Pradesh

AssamBihar

Chandigarh

Chhattisgarh

Dadra&NagarHaveliDaman&Diu

Delhi

Goa

Gujarat

Haryana

Himachal Pradesh

Jammu&Kashmir

Jharkhand

Karnataka

KeralaLakshadweep

MadhyaPradesh

Maharashtra

ManipurMeghalaya

Mizoram

Nagaland

Orissa

Pondicherry

Punjab

Rajasthan

Sikkim

TamilNadu

Tripura

Uttar Pradesh

Uttaranchal

WestBengal

Andaman&Nicobar Islands

AndhraPradesh

Arunachal Pradesh

AssamBihar

Chandigarh

Chhattisgarh

Dadra&NagarHaveliDaman&Diu

Delhi

Goa

Gujarat

Haryana

Himachal Prad

Andaman&Nicobar Islands

AndhraPradesh

Arunachal Pradesh

AssamBihar

Chandigarh

Chhattisgarh

Dadra&NagarHaveliDaman&Diu

Delhi

Goa

Gujarat

Haryana

Himachal Pradesh

Jammu&Kashmir

Jharkhand

Karnataka

KeralaLakshadweep

MadhyaPradesh

Maharashtra

ManipurMeghalaya

Mizoram

Nagaland

Orissa

Pondicherry

Punjab

Rajasthan

Sikkim

TamilNadu

Tripura

Uttar Pradesh

Uttaranchal

WestBengal

esh

Jammu&Kashmir

Jharkhand

Karnataka

KeralaLakshadweep

MadhyaPradesh

Maharashtra

ManipurMeghalaya

Mizoram

Nagaland

Orissa

Pondicherry

Punjab

Rajasthan

Sikkim

TamilNadu

Tripura

Uttar Pradesh

Uttaranchal

WestBengal

As on Mar.2007PR: 0.72/10,000

Elimination achieved in 32 out of 35 States/Union Territories

As on Mar 2004PR:2.44/10,000

As on Mar 2009PR:0.72/10,000

0.740.721.2 1.1

0.720.84

1.3

25.9

20.0

13.710.9

8.45.9 5.8 5.5

4.23.75.35.3

2.43.21.2

1.42.3

5.95.57.0

8.9

5.65.14.64.95.76.4

6.25.9

4.43.3

0

5

10

15

20

25

30

1991199219931994199519961997199819992000200120022003200420052006200720082009

Year (March End)

Pre

vale

nce

& A

NC

DR

PR

ANCDR

PREVALENCE vs ANCDR

INDIA:By the end of March 2009: 0.86 lakh cases were on record PR: 0.72/10,000 1.34 lakh new cases were detected in 2008-09 ANCDR:1.119/10,000 New cases in 2008-09: 48%-MB,10.1%-

child,35.2%-females,2.8%-visible deformity After introduction of MDT,case load has come

down from 57.6/10,000 in 1981 to 1 at national level in DEC 2005 .

32 states/UTs have achieved the status of elimination.

Only 3 states/UTs: Bihar,Chhatisgarh & D&N Haveli with PR 1-2.5/10,000 ARE YET TO ACHIEVE(10.4% 0f country’s population,20% of new cases)

Statewise distribution

UPBiharMaharashtraWBAPGujaratChhatisgarhOthersMPOdishaTNKarnataka

UP 20%

Bihar 14%

Mah arashtra 11%

WB 9%

AP 7%

Gujarat 6%

Chhatisgarh 6%

Others 6%

MP 5%

Odisha 5%

TN 4%

Karnataka 3%

ODISHA :

By Mar 2011, Total population-4.19 crores PR-0.85/10,000(13 districts: 1,highest-Nuapada 1.58,lowest-

Gajapati 0.22,Sambalpur-1.45) ANCDR-1.61/10,000. (Sambalpur-1.45) Among newly detected cases, Gr.I deformity-3.71%,Gr.II-3.87%,MB-

46.48%,Child cases-9.34%,females-36.62%,SC -20.26%,ST-26.22%

Leprosy meets the demanding criteria for elimination:

◦ practical and simple diagnostic tools: can be diagnosed on clinical signs alone;

◦ the availability of an effective intervention to interrupt its transmission: MDT

◦ a single significant reservoir of infection: humans.

1955 – Launched National Leprosy Control Programme

1983 – Launched National Leprosy Eradication Programme and introduced MDT

1991 – WHO declaration to eliminate leprosy atglobal level by 2000.

1993 – World Bank supported NLEP – I 2001 – World Bank supported NLEP – II

Integration of Leprosy services withGeneral Health Care System

2002 - National Health Policy Statement : Elimination of Leprosy by 2005

Dec.2005 – Elimination of leprosy as public health problem at National level.

Since Jan 2005 - Programme continues with GOI support

MILESTONES OF NLEP IN INDIA

Funding-GOI Technical support-WHO & ILEP(International

federation of anti-leprosy association)

NLEP

Decentralization of NLEP services

Integration of NLEP with General Health Care

System

Capacity building of GHS functionaries

Early diagnosis & prompt MDT

Intensified IEC using Local and Mass Media

Prevention of Disability & Medical Rehabilitation

(DPMR)

Monitoring & Evaluation

STRATEGIES FOR ELIMINATION OF LEPROSY IN INDIA

STATE LEVEL SOCIETIES are formed & funding to districts is done by these.

In smaller states/UTs-district societies

DECENTRALIZATION OF NLEP SERVICES

Integration means to provide “comprehensive” essential services from one service point:

◦ to improve pts access to leprosy services and thereby ensure timely Tt

◦ to remove the “special” status of leprosy as a complicated and terrible disease

◦ to consolidate substantial gains made ◦ to ensure that all future cases receive timely and

correct Tt◦ to ensure that leprosy is treated as a simple

disease

INTEGRATION OF NLEP WITH GENERAL HEALTH CARE SYSTEM

ADVANTAGES:

Patients detected early Patients treated early Transmission of infection interrupted early Development of deformities prevented Stigma reduced further

NRHM & NLEP:

Link person-ASHA Performance based incentive:

Training centers …CLTRI,Chengalputtu

3RLTRI(Raipur,gauripur,aska)

Routine …. Diagnosis and MDT Specialised … RCS in Medical colleges Management training to DLOs

CAPACITY BUILDING OF GHS FUNCTIONARIES

Proper history Thorough clinical exam. Lab confirmation

NEW CASE: a person having skin patch(es) with a definite loss of sensation & has not received a course of MDT.

Classification for Tt:(WHO CLASSIFICATION/FIELD CLASSIFICATION) PB MB

EARLY DIAGNOSIS & PROMPT MDT

PB

MB

95% of cases can be diagnosed clinically even by paramedical workers

Skin smears for M.leprae would assist in detecting suspected infectious cases

Biopsy/PCR may be needed rarely

Detection of 5-10% skin smear ve leprosy pts is more imp. as they infect others.

If no smear facility, detect 30-40% of infectious cases with multiple skin lesions but intact sensation.

LEPRA REACTION:

May occur before/during/after MDT. Not caused by MDT. Do not stop MDT. Type1 (Reversal reaction) Type2 (ENL)Treat ‘Reaction’ as a Medical Emergency: Rest & Analgesics DOC-Prednisolone(40-60 mg) Taper gradually over 12-16 wks. All need a detailed Neuromuscular assessment

by a physiotherapist.

RELAPSE: a pt who has completed the required course of MDT & who is taken as having been treated, but in whom s/s of leprosy reappear either during surveillance period or thereafter.

A Confirmed case should be treated with MDT again depending upon classification.

DEFAULTER:a pt who has not collected MDT for 12 consecutive months.

Adequate efforts should be made to trace & persuade each to return for assessment &Tt before their removal from register.

OBJECTIVES: Active participation of communities & clientsTARGETS & PRIORITIES: Community-at large & selected communities where stigma is

more deep rooted Leprosy pts General health care staff Local NGOs & CBOs DPOs(Disabled peoples organizations) IPC-m/impOTHER ACTIVITIES:o Women mobilizationo Old leprosy peoples’ associationo Complain: toll-free no.

INTENSIFIED IEC USING LOCAL & MASS MEDIA

o Remedial & redressal measures.o Awareness within ptso Village level meetingso Health campso Cultural program:street theatre,folk music,puppet

show,dance theatre,rallies & house visitso Community feasto Advocacy meetingso Sensitization of the media pesonso Motivate the youth to come forward & educate the

community about leprosyo Inviting budding writers to write positive &

motivational stories on leprosyo Door to door contact & counsellingo Advertisements through local newspapers,posters,wall

writings

The best way to prevent disabilities is: ◦ Secondary prevention i.e.,early diagnosis

and prompt treatment with MDT Inform patients (specially MB) about

common s/s of reactions Ask them to come to the centre (as soon Start treatment for reaction as

possible) Inform them how to protect insensitive

hands/ feet /eyes Involve family members

PREVENTION OF DPMR

.

WHO Grade 0 1 2

EYES Normal vision,lid gap,blinking.

Corneal reflex weak

Reduced vision,lagophthalmos.

HANDS Normal sensation & m.power.

Loss of feeling in the palm

Visible damage:wounds,claw hand,loss of tissue etc.

FEET Normal sensation & m.power.

Loss of feeling in the sole

Visible damage:wound,foot drop,loss of tissue.

WHO DISABILITY GRADING

Disabilities such as loss of sensation and deformities of hands/feet/eyes occur because:

◦ Late diagnosis and late treatment with MDT◦ Advanced disease (MB leprosy)◦ Leprosy reactions which involve nerves◦ Lack of information on how to protect insensitive

parts.

CARE OF EYES

CARE OF HANDS

CARE OF FEET

- Measurement of persons with disabilities

- Comprehensive approach to rehabilitation in co-

ordination with MOSJ&E

- Community based rehabilitation

- Increased access to DPMR services at first, second

and third level Institutions.

- Payment of Rs. 5000/- to poor patients for each major

RCS to compensate for wage loss.

- Reimburse funds upto Rs. 5000/- for each surgery to

Govt. Hospitals to facilitate RCS operations.

PRIMARY INDICATOR:

Annual New Case Detection Rate

(ANCDR)

Treatment Completion Rate (cohort

analysis)

MONITORING & EVALUATION

INDICATORS FOR CASE DETECTION:

Proportion of new cases with Gr II disability

Proportion of child cases(15yrs) among new cases

Proportion of MB cases among new cases

Proportion of Female cases among new cases

INDICATORS FOR QUALITY OF SERVICE:

Proportion of new cases correctly diagnosed.

Proportion of defaulters.

Number of relapses during a year.

Proportion of cases with new disabilities.

‘’REFERRAL SYSTEM IN NLEP’’

Organising camps for 1 or 2 wks duration Services available: case detection,Tt & referral Mass media Quite effective in case finding & has been

employed during phase-II. 5th MLEC: Feb-Mar’04 in 8 high endemic

states. Specific strategy is varied as per endemicity

of region.

MODIFIED LEPROSY ELIMINATION CAMPAIGN(MLEC)

Carried out for 15 days in identified priority areas during Sep-Nov each yr.

Made huge impact on:o Hidden case detectiono Better case mgto Imrovement in spreading the awarenesso Bringing down PR in high endemic areas.

BLOCK LEPROSY AWARENESS CAMPAIGNS (BLAC)

For people living in special difficult to access areas or situation or neglected communities.

Strategies: early detection & prompt MDT with proper

IEC.

SPECIAL ACTION PROJECTS FOR THE ELIMINATION OF

LEPROSY(SAPEL)

GOI provides assistance to urban areas with 1lakh population.

Urban areas:townsship I,medium cities I&II,Mega cities.

Leprosy Elimination in urban areas is challenged by -

rapid increase in population, migration, slums, density, poor living conditions and violence,

favorable to maintain reservoir of infection and transmission

difficulty in finding hidden cases, relapse and Tt completion,

private health care participation

LEPROSY ELIMINATION CAMPAIGNS(LEC) FOR URBAN AREAS

ILEP Members ILU LEA National Level NGOs:

GMLFHKNS

Local Voluntary Organisations

INVOLVEMENT OF NGOs

AREAS OF SUPPORT:

Capacity Building Technical Support Referral services Rehabilitation IEC and Advocacy Infrastructure development Research Urban leprosy

WHO, Nippon Foundation,

Novartis, World Bank, DANIDA,

ILEP agencies

National Governments &NGOs of endemic countries.

PARTNERS OF NLEP

Strong political commitment.

Availability of adequate resources.

Support from partners in NLEP like WHO, World

Bank, ILEP, The Nippon Foundation, Novartis,

and NGOs.

Strategic planning and timely implementation of

the activities.

Special campaigns in vulnerable areas :

MLEC/BLAC

FACTORS HELPED IN REACHING ELIMINATION

• Continued transmission

• Early detection of MB case, relapse,R resistance

• Sub clinical infection, carriers

• Eradication model

• Early detection & treatment of reactions

• Prevention of nerve damage

• Prevention & Care of disabled Patients

• Dissatisfaction for residual signs after MDT

• Immunoprophylaxis

• Chemoprophylaxis

• Immunotherapy

POST ELIMINATION ISSUES

o Further reduce leprosy burden in the country

o Provide quality leprosy services through GHC system

o Enhance DPMR services

o Enhance advocacy to reduce stigma and

discrimination

o Capacity building of GHC staff

o Strengthening monitoring & supervision

11TH PLAN(2007-12)

NEW PARADIGMS ARE IN CONFORMITY

WITH WHO OPERATIONAL GUIDELINES

2006-2010:

Providing quality services

Sustainable Leprosy services through the

PHC System .

Referral services and long term care

www.who.int J.Kishore’s national health programmes of

india,9th ed. Park’s text book of preventive & social

medicine,21st ed. A guide for public health doctors(ALERT-

INDIA:LEAP PUBLICATION)

REFERENCES

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